Author(s)

Christina Theil Schnor and Saranya Loganathan.

Why was it done?

In 2018, hospitals in Region Zealand (RZ), Denmark, transitioned to the electronic health record (EHR) system, EPIC. Following this, hospital pharmacists faced repeated medication order challenges causing adverse events such as inappropriate medication orders, dispensing and administration errors, and insufficient workflow coordination. These issues resulted in complex, time-consuming workflows impacting quality and patient safety. Additionally, collaboration between corporate IT and clinical staff was challenged by a lack of understanding of practical issues. To address this, pharmacists of RZ established the Clinical Pharmaceutical Service IT Team (CPS IT Team) to build specialized knowledge of the EHR medication module, aiming to assure quality, optimize workflows, strengthen interdisciplinary coordination, and support safer and more efficient clinical use.

What was done?

CPS IT Team standardized workflows, enhanced coordination of medication order tasks, and created a forum to effectively utilize professional knowledge and networks across areas.

How was it done?

To address diverse Clinical Pharmacy challenges, CPS IT Team became the bridge between internal organization (RZ Hospital Pharmacy and corporate IT) and external partners (EPIC and The Capital Region of Denmark (CRD)). For this reason, CPS IT Team was established with one team manager and two units: Internal and External unit. CPS IT Team continuously adapts to evolving Clinical Pharmacy needs.

What has been achieved?

The establishment of CPS IT Team has driven significant internal optimization and standardized workflows. Acting as a coordinating unit, it optimizes medication processes from ordering to dispensing and administration. Dialogue with IT has been strengthened, enabling more efficient, targeted communication across professional groups.
Collaboration with EPIC and CRD has enhanced quality assurance and optimized workflows. CPS IT Team efforts have helped prevent medication-related adverse events, improve workflows, and optimize medication processes. Interdisciplinary collaboration and professional consultation networks between regional clinics, hospital pharmacies, IT, and EPIC have been notably strengthened. These efforts have increased patient safety and fostered a safer, more coherent workflow in EPIC.

What next?

Fusion of RZ and CRD into Region Eastern Denmark will change CPS IT Team’s working conditions, opening new opportunities such as an expanded collegial network and broader range of tasks and needs. Systematic data use will support Hospital Pharmacy’s work, improving efficiency and quality in daily operations.

Author(s)

AI IDOATE GRIJALBA, P GARCÍA GONZÁLEZ, L CABIA FERNÁNDEZ

Why was it done?

Environmental, social, and economic sustainability has become increasingly important in all sectors, including the healthcare sector and, more specifically, in hospital pharmacy.

What was done?

Analyze and prioritize the sustainability strategies proposed by the pharmacy service at all stages of the pharmacotherapeutic process.

How was it done?

Within the framework of clinical decision-making and planning sustainable pharmacotherapeutic strategies within the 2030 Agenda of the Spanish Society of Hospital Pharmacy, it is essential to analyze and prioritize different proposals. Two key criteria were considered: resource availability and the relevance of pharmaceutical intervention. Both criteria were scored from 1 (low) to 3 (high) by the service pharmacists. To stratify the proposals, both criteria were multiplied, establishing priority 1 (7-9 points), priority 2 (5-6 points), and priority 3 (1-4 points).

What has been achieved?

Priority 1 strategies were: in the management area, prioritizing the purchase of drugs with a lower carbon footprint and exchanging drugs with a short expiration date with the referral hospital. In the validation area: actions promoted by the PROA team: deprescribing antibiotics in general and specifically those with a high environmental impact (macrolides and quinolones), de-escalation, sequential therapy, and limiting the duration of treatments. Automation and digitization of on-demand drug ordering processes and pharmacotechnical processes (registration of raw materials and packaging materials). Promoting telepharmacy, with the dispensing of outpatient drugs to pharmacies, especially relevant for patients living in scattered villages in the area, to improve treatment adherence and reduce transport. In the dispensing area, prioritizing the KANBAN system to reduce immobilized medication stocks in primary care and hospital wards and facilitate the transport of medication in care transitions. In the training area, teach patients how to use mobile apps to view outpatient dispensations.
Priority 2 or 3 strategies whose score is conditioned by a lack of resources will be evaluated by the service together with hospital management, and those with a high impact will be given priority.

What next?

Priority 1 strategies will be fully implemented in the short term (6 months) and will be reviewed periodically, priority 2 strategies (1 year) and priority 3 strategies (5 years).

Author(s)

Collada VL1, Villamañán E1., Mallón S1., Laorden D2, Domínguez-Ortega J.3 García Lopez L1, Soto A1., Villaroya E1, Bueno S1, Herrero A1.
1. Pharmacy deparment. Hospital Universitario La Paz
2. Pneumology deparment. Hospital Universitario La Paz
3. Allergy deparment. Hospital Universitario La Paz

Why was it done?

The healthcare sector is responsible for 4–5% of global greenhouse gas emissions, with medications contributing up to 35%. pMDIs, widely used in asthma, contain hydrofluorocarbon propellants with high global warming potential. In Spain, 46% of inhalers prescribed in 2023 were pMDIs, with rescue therapies (SABAs) only available in this format. The aim was to explore substitution with lower-emission devices without compromising adherence or asthma control.

What was done?

An observational initiative was conducted in a severe asthma multidisciplinary group to evaluate the type of inhalers prescribed and their environmental impact. Prescription patterns, adherence and CO₂ emissions were analysed to identify opportunities for replacing pressurised metered-dose inhalers (pMDIs) with more sustainable alternatives.

How was it done?

The study included 223 adult patients with severe asthma followed during 2024. Inhaler prescriptions, adherence (medication possession ratio) and estimated CO₂ emissions were assessed. Barriers included lack of non-pMDI rescue inhalers and entrenched prescribing habits. These were addressed through multidisciplinary collaboration, identification of equivalent alternatives and education on sustainability.

What has been achieved?

Out of the 297 inhalers prescribed, 43.4% were pMDIs. Triple therapy (LABA–ICS–LAMA) was predominantly prescribed as pMDIs (66.7%). Acceptable adherence (>70%) was observed for both pMDIs and non-pMDIs, with no clinically significant differences. Over half of patients using rescue inhalers were high-frequency users, all of whom received SABA pMDIs (20–30 kg CO₂ per canister). For most maintenance prescriptions, non-pMDI equivalents with a much lower footprint (<2 kg CO₂ per canister) were available. These findings demonstrate that many pMDI prescriptions could be replaced without affecting treatment adherence.

What next?

This initiative shows that integrating environmental considerations into asthma care is feasible and clinically safe. It highlights the urgent need to introduce sustainable rescue inhalers and adopt new low-GWP propellants. The model can be scaled to other respiratory conditions and European healthcare systems, contributing to decarbonisation strategies while maintaining high-quality patient care.

Author(s)

Nonia Ferreras López, Irene de la Fuente Villaverde, Blanca de la Nogal Fernández, Virginia Martínez Fernández, Eva Martínez Álvarez, Zulema Rodríguez Fernández, Henar García Lagunar, Raúl Martínez, Miriam Rodríguez María.

Why was it done?

A Multidisciplinary Biological Therapy Committee for Airway Diseases (BTCAD) was established in a secondary-level hospital. The committee integrated pulmonologists, ENT specialists, allergists, pathologists, and hospital pharmacists (HPs) to optimize the use of biological therapies (BTs). Its main functions included patient evaluation, development of consensus-based protocols, and structured monitoring of treatment outcomes.

What was done?

The initiative was introduced in 2022 to address the absence of standardized decision-making processes for BTs in severe uncontrolled asthma and chronic rhinosinusitis with nasal polyps. Prior to implementation, therapeutic selection was fragmented and lacked uniform criteria. The primary aim was to improve appropriateness of BT use, reduce variability in clinical practice, and ensure optimal patient outcomes through a coordinated multidisciplinary approach.

How was it done?

The BTCAD defined clinical and laboratory criteria for patient selection, developed a consensus document for BT positioning, and designed workflows for dispensing and follow-up. Monthly meetings were held to evaluate cases, supported by a shared calendar and a structured database. Educational sessions were organized to update staff knowledge. Obstacles included the requirement for strong managerial support and the impact of staff turnover on continuity. These were mitigated by formalizing procedures and ensuring standardized documentation and training.

What has been achieved?

From March 2022 to March 2025, 54 patients were assessed: 49 with severe asthma and 5 with chronic rhinosinusitis with nasal polyps. Treatment was discontinued in two cases due to lack of efficacy, and seven patients were switched to alternative BTs. At follow-up, 52 patients remained on therapy (17 benralizumab, 20 mepolizumab, 7 omalizumab, 6 dupilumab, 2 tezepelumab). The HP contributed to patient evaluation, drafting of reports, pharmacovigilance, and adherence monitoring. A survey revealed that all members reported increased knowledge, 87,5% considered the pharmacist’s role essential, and overall satisfaction reached 4,38/5.

What next?

The BTCAD improved coordination, standardization, and professional development within the hospital. Its model is transferable to other healthcare settings, providing a framework for safe and efficient BT implementation. The high satisfaction and demonstrated value of multidisciplinary collaboration, particularly the HP’s role, support its consideration as an example of good practice.

Author(s)

Nabaa Dhuhaibawi, Cristin Ryan, Fionnuala Kennedy

Why was it done?

Climate change is a major global health threat, and healthcare contributes approximately 4–5% of global greenhouse gas emissions. Pharmaceuticals account for around one-quarter of this total through production, packaging, distribution, and disposal. Hospitals are under increasing pressure to reduce medicine waste and their associated carbon footprints. Automated Dispensing Cabinets (ADCs) — electronic systems for storing and issuing medicines at the point of care — improve medication safety and efficiency, but their environmental benefits have not been well studied. Understanding whether ADCs can reduce the carbon footprint of dispensed medicines is therefore essential for promoting sustainable healthcare practices.

What was done?

This study evaluated the impact of ADC implementation on the carbon footprint of dispensed oral medicines in an acute hospital in Dublin. A secondary objective was to examine the carbon footprint distribution of all single-ingredient oral medicines in the hospital formulary, identifying future opportunities for reducing medicine-related emissions.

How was it done?

A retrospective before-and-after study was conducted across six inpatient wards where ADCs were introduced between December 2023 and May 2024. Dispensing data were collected for equivalent two-week periods before and after the intervention using the Isoft® system. Only oral active pharmaceutical ingredient (API) medicines were included. Each medicine’s carbon footprint (gCO₂eq) was obtained from the Ecovamed® database and analysed using descriptive statistics and the Wilcoxon signed-rank test (α = 0.05). For the secondary analysis, all single-ingredient oral APIs from the hospital formulary were classified by their Medicine Carbon Footprint (MCF) rating using the YewMaker® database.

What has been achieved?

The total carbon footprint of dispensed medicines decreased from 262.58 kg CO₂eq before ADC implementation to 176.94 kg CO₂eq after. Among 99 medicines dispensed in both periods, the median carbon footprint per medicine fell significantly from 644 to 352 g CO₂eq (p < 0.001; r = –0.37). In the formulary analysis, most medicines had low (31.7%) or medium (35.2%) MCF ratings, while only two items—abiraterone acetate and methenamine hippurate—had very high (>1000 g CO₂eq) values.

What next?

ADCs appear to significantly reduce medicine-related carbon emissions, suggesting that digital automation supports sustainable pharmacy practice. Future efforts should target high-MCF drugs, promote greener procurement, and expand environmental life-cycle data to maximise carbon reduction across hospital pharmacy services.

Author(s)

Susanne Weng Rømer, Hospital Pharmacy North Denmark Region, Aalborg, Denmark
Alissa Maria Kloppenburg, Hospital Pharmacy Funen, OUH, Svendborg, Denmark
Tania Truelshøj, Hospital Pharmacy Central Denmark Region, Aarhus, Denmark
Benene Rguez, Capital Region Pharmacy, Copenhagen, Denmark
Sine Thagaard Wermuth, Region Zealand Hospital Pharmacy, Roskilde, Denmark
Karen Suhr Lausten, Amgros I/S, Copenhagen, Denmark
Katrine Fridthjof Hougaard, Amgros I/S, Copenhagen, Denmark
Mikala Vasehus Holck, Amgros I/S, Copenhagen, Denmark
Thomas Loof Hedegård, Amgros I/S, Copenhagen, Denmark

Why was it done?

Amgros conducts national tenders for medicines on behalf of Hospital Pharmacies in Denmark. The tenders often result in medicine changes. Previously, each of the eight Danish Hospital Pharmacies assessed every change individually. A national study showed this was time-consuming, duplicative, and produced variable quality. A more coordinated process was needed. The project aimed to centralize the workflows to ensure systematic identification of relevant differences while using fewer resources and supporting safe medicine changes. The Focus List was implemented in August 2025.

What was done?

A national decision support tool – the Focus List for Medicine Changes – was developed to make medicine changes following tenders easier, safer, and more efficient for Danish Hospital Pharmacies. By comparing Summaries of Product Characteristics (SPCs), the Focus List provides a structured overview of clinically relevant differences requiring attention during consumption estimation and clinical implementation.
By centralizing and standardizing assessments, the Focus List improves efficiency by reducing duplication of work, saving resources, and ensuring consistent quality. Ultimately, it supports patient safety by ensuring that potential clinical consequences are identified and addressed proactively.

How was it done?

A working group with representatives from Hospital Pharmacies and Amgros collected experiences and mapped existing workflows. Key parameters for comparison, such as storage conditions, therapeutic indications, and unwanted excipients, were identified. These formed the basis of the Focus List, which systematically presents relevant differences between outgoing and incoming tendered medicines. The Focus List was tested and validated by Hospital Pharmacy staff across all regions, supported by templates and guidance documents to ensure consistent use.

What has been achieved?

The Focus List was well received. Hospital pharmacies reported expected time savings, improved support for estimation processes, and higher quality consistency in identifying clinically relevant changes. The Focus List, including 273 medicine switches, was implemented and replaced the decentralized approach with a more streamlined national workflow.

What next?

A formal evaluation will follow once more experience has been gathered. Future work aims to automate SPC comparisons using AI and expand the Focus List to cover all tender-related changes. This initiative could be replicated in other settings through cross-functional collaboration.

Author(s)

A. Telma Leal, António Daniel Mendes, Teresa Cunha, Paula Barbeita, Patrocínia Rocha

Why was it done?

Lennox-Gastaut syndrome is a severe, drug-resistant epilepsy with childhood onset, characterised by irregular brain activity, cognitive impairment and behavioural changes. Given its complexity and major impact on quality of life, therapy requires continuous adjustment, possibly involving valproate, clobazam, lamotrigine, rufinamide, topiramate, felbamate or cannabidiol.
No clobazam formulations are commercially available for paediatric use and data on extemporaneous oral formulations are limited. Regarding this, stability evaluation is essential to ensure quality and safety before therapeutic application.

What was done?

Galenic development, preparation and stability evaluation of a Compounded Formulation (CF) with clobazam for paediatric treatment of Lennox-Gastaut syndrome and other refractory epilepsies.

How was it done?

Development began with a literature review on the pharmacological and physicochemical properties of the drug, followed by election of an oral liquid formula.
Two samples were prepared and assessed for physical stability by an internal protocol on days 7, 14, 21, and 28: one (CF1) stored at Room Temperature (RT) <25 °C, the other (CF2) refrigerated (2–8°C).

What has been achieved?

Based on our findings, a clobazam suspension was designed using xanthan gum as a suspending agent, with pH around 5. According to literature-reported shelf lives and usage periods of CF and raw materials, one batch was refrigerated and the other stored at RT. Also, CFs were prepared at 1 mg/mL concentration (suitable for Paediatrics), packaged in 100 mL type III amber glass bottles and the final product should be whitish suspensions, homogeneous after shaking, with pH around 4–6.
Evaluation showed CF1 developed microbiological contamination on day 14, with gas, fermented odour and pH 6–7 by day 21, then 5–6 (day 28). Other features — sedimentation time, dispersibility, homogeneity and crystal growth—remained normal. CF2 kept colour and appearance until day 28. Mold odour occurred at day 21. pH rose from 6–6.5 to 6.5–7 after day 14. Other parameters remained normal.

What next?

Clobazam CF proved to be suitable for paediatric Lennox-Gastaut syndrome or refractory epilepsy use. Stability evaluation demonstrated physical appropriateness for up to 14 days under refrigeration; for longer use is not recommended.

Author(s)

Line Jarvig MSc Pharm.
Christine Dinsen-Andersen MSc Pharm.
Aysegül Sekeroglu MSc Pharm.

Why was it done?

The national Health Technology Assessment (HTA) institute in Denmark issued its first recommendation on medicines for the treatment of Fabry disease based on four therapies considered clinically equivalent. Only one therapy was recommended due to cost. This recommendation initiated a national implementation effort, led by pharmaceutical staff, to support a correct and efficient medication switch to the recommended therapy.

What was done?

A pharmacist coordinated the implementation of the medication switch, in collaboration with the hospital with the national responsible for the treatment of Fabry disease, the hospital pharmacies, and the regional drug committee.

How was it done?

Coordination of the implementation strategy was carried out through virtual meetings and email correspondence. The implementation was based on a robust data foundation and was highly prioritized by hospital management. Representatives from the hospital pharmacies in the patient’s home region were included in the information flow to ensure optimal pharmaceutical inventory management at local hospitals. Furthermore, the pharmaceutical supplier was thoroughly informed regarding the timeline and expected drug consumption.

What has been achieved?

This case demonstrates that even complex medication switches can be successfully implemented when there is clear managerial support, detailed coordination, and strong engagement from all involved parties. It also highlights that there is no standard model for implementation, and that adaptation to local conditions is essential.
Drivers identified as contributing to the complexity of the implementation:
• Patients’ usual treatment was managed at regional hospitals, while the switch was conducted by the hospital with the specialized treatment responsibility.
• Detailed planning of treatment and pre-switch paraclinical examinations was required.
• The majority of patients had to switch treatment, including a change from oral to intravenous therapy.
• Early planning was necessary to meet supplier requirements for consumption estimates.
• Estimating drug use was complex due to the planned full switch over an estimated period.
• High drug prices required close monitoring of drug inventories to minimalize medication waste.

What next?

The switch is being monitored to ensure continued adherence. Experiences gained form this case will be applied to future switches, with planning focused on early identification of complexity drivers and strategies to manage them.

Author(s)

Pons Maria, A; Fernández Huertas, L; Samblas Ruiz, M; Hernandez Silveira, L; Barceló Sansó, F; Juez Santamaria, C; Luque Mesa, JA

Why was it done?

This case describes a 23-year-old patient admitted with acute kidney injury (AKIN III) of unknown origin. Due to poor clinical progression, along with symptoms of scalp itching and redness, and the presence of calcium oxalate crystals in urine, glyoxylic acid poisoning was suspected. Glyoxylic acid is a component found in certain hair straightening products. The potential use of fomepizole as an antidote was considered, prompting a pharmaceutical intervention.

What was done?

A literature review was conducted on the use of fomepizole in poisonings caused by glyoxylic acid and ethylene glycol, considering that glyoxylic acid is an intermediate metabolite in the toxic pathway of ethylene glycol.

How was it done?

The mechanism of action of fomepizole was analyzed as a competitive inhibitor of the enzyme alcohol dehydrogenase, assessing its ability to block the conversion of glyoxylic acid into toxic metabolites such as oxalic acid, which is responsible for renal damage. To evaluate the feasibility of using the antidote, the National Institute of Toxicology was consulted. After reviewing the case, and given that more than 72 hours had passed since exposure to the toxin, its administration was ruled out. Supportive treatment already initiated was continued, including fluid therapy, bicarbonate, thiamine, and pyridoxine. The patient showed progressive improvement in renal function without requiring dialysis.

What has been achieved?

The multidisciplinary approach enabled the identification of the toxic etiology and helped prevent major complications. The case highlighted the key role of the hospital pharmacist in the evaluation of antidotes.

What next?

Similar poisoning scenarios—both uncommon and typical—will be reviewed to establish well-defined clinical pathways that allow for rapid and coordinated action in case antidotes such as fomepizole need to be used. This review will help improve the preparedness of both pharmacy and clinical teams for toxicological situations not currently covered by existing protocols.

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Author(s)

Julen Montoya Matellanes, María Sánchez Argáiz, Pablo González Moreno, Sister Jacinta Wajinku, Ana Soler-Rodenas, Luis Ortega Valín, David Roca Biosca

Why was it done?

The goal of this initiative was to address the challenges faced in medicine management at the hospital, including low adherence to the HDF and the presence of numerous medicines not listed in the guideline. These issues hindered effective treatment options for patients and highlighted the need to improve compliance with national guidelines.

What was done?

We conducted a comprehensive review of the hospital drug formulary (HDF) in a rural Ugandan hospital to optimize pharmacotherapy and improve local access to essential medicines. This initiative involved assessing adherence levels to the HDF, identifying therapeutic needs, and evaluating drug availability.

How was it done?

A mixed-methods approach was used, combining qualitative and quantitative data. We compared the medicines available in the storage facilities s with those listed in the current HDF (published in 2016). Key indicators, such as adherence to the HDF and the number of available medicines not included in the guideline, were calculated. In addition, interviews with the responsible pharmacist provided insights into the causes of medicine shortages. We also compared the HDF with the 2023 Uganda Clinical Guidelines and the Essential Medicines and Health Supplies List for Uganda to identify therapeutic gaps.

What has been achieved?

The review revealed that out of 234 medications listed in the HDF, only 127 (54%) were available at the hospital pharmacy, while 107 (46%) were unavailable or out of stock. Adherence to the HDF was 63%, and 164 available medications were not included in the guideline. Ninety-nine potential therapeutic gaps were identified and it was highlighted that the main reasons for drug shortages included discontinuation of compounded drugs preparation and expiry of medicines due to low usage. This initiative provided a clear picture of the severity and causes of the issues related to access to medications.

What next?

To address these challenges, we recommend implementing staff training in medication management, systematizing stock and ordering processes, updating the HDF based on clinical and economic criteria, and reactivating the magistral formulation laboratory. With these measures we aim to improve medication availability and ensure better patient outcomes in this rural hospital. Additionally, the method employed can be standardized as a valid approach to assess drug availability in any hospital, with particular relevance in low-resource countries facing economic challenges and lacking electronic inventory control systems.